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� <br /> R � <br /> i <br /> PLUMBING FIXTlJRES BEING 1NSTALLED <br /> FIXTURE BSMT 1 2` OTHER FIXTURE BSMT 1' 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � Floor Drains ( <br /> Lavatory � � Sewer Ejector <br /> Bathtub � Laundry Tray <br /> Shower ! � Washer I <br /> 1 <br /> Kitchen Sink � � Water Heater �� � <br /> � n <br /> Disposal Water Softener <br /> � <br /> Dishwasher Wet Bar <br /> Siilcocks Miscellaneous <br /> �Q � �� � <br /> PERMIT FEE CALCLILATION(S) <br /> � BASED OFF - 2002 STATE STATUE � <br /> ❑ Yes,this section applies <br /> The replacement of onl}�one Residenrial fixture or appliance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less; excludin�the cost of the fixture or appliance: and <br /> 3. Is improved, installed or replaced by the�homeowner or licensed plumbing contractor. <br /> Slcip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> � <br />